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Minerva Anestesiologica 2020 November;86(11):1234-45

DOI: 10.23736/S0375-9393.20.14762-X


lingua: Inglese

Management of critically ill patients with COVID-19: suggestions and instructions from the coordination of intensive care units of Lombardy

Giuseppe FOTI 1, 2, Alberto GIANNINI 3, Nicola BOTTINO 4, Gian Paolo CASTELLI 5, Maurizio CECCONI 6, 7, Giacomo GRASSELLI 4, 8, Luca GUATTERI 9, Nicola LATRONICO 3, 10, 11, Thomas LANGER 2, 12, Giacomo MONTI 13, Stefano MUTTINI 14, Antonio PESENTI 4, 8, Danilo RADRIZZANI 15, Marco RANUCCI 16, Vincenzo RUSSOTTO 1, 2 , Roberto FUMAGALLI 2, 12, COVID-19 Lombardy ICU Network 

1 Department of Emergency and Intensive Care, San Gerardo University Hospital, Monza, Italy; 2 School of Medicine and Surgery, University of Milan-Bicocca, Milan, Italy; 3 Unit of Pediatric Anesthesiology and Intensive Care, Children’s Hospital, ASST Spedali Civili Hospital, Brescia, Italy; 4 Department of Anesthesiology, Reanimation and Emergency, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy; 5 Department of Anesthesiology and Intensive Care, ASST Mantua, Carlo Poma Hospital, Mantua, Italy; 6 Department of Anesthesiology and Intensive Care Medicine, IRCCS Humanitas Clinic, Rozzano, Milan, Italy; 7 Humanitas University, Pieve Emanuele, Milan, Italy; 8 Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy; 9 Department of Anesthesiology and Intensive Care, Sacra Famiglia Fatebenefratelli Hospital, Erba, Como, Italy; 10 Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy; 11 Department of Anesthesiology, Critical Care and Emergency, ASST Spedali Civili, Brescia, Italy; 12 Department of Anesthesiology and Intensive Care, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy; 13 Department of Anesthesiology and Intensive Care, IRCCS San Raffaele Hospital, Milan, Italy; 14 Department of Anesthesiology and Intensive Care, ASST Santi Paolo e Carlo, San Carlo Hospital, Milan, Italy; 15 Department of Anesthesiology and Intensive Care, ASST Ovest Milanese, Hospital of Legnano, Legnano, Milan, Italy; 16 Department of Anesthesiology and Intensive Care, IRCCS San Donato Hospital, Milan, Italy

With 63,098 confirmed cases on 17 April 2020 and 11,384 deaths, Lombardy has been the most affected region in Italy by coronavirus disease 2019 (COVID-19). To cope with this emergency, the COVID-19 Lombardy intensive care units (ICU) network was created. The network identified the need of defining a list of clinical recommendations to standardize treatment of patients with COVID-19 admitted to Intensive Care Unit (ICU). Three core topics were identified: 1) rational use of intensive care resources; 2) ventilation strategies; 3) non-ventilatory interventions. Identification of patients who may benefit from ICU treatment is challenging. Clinicians should consider baseline performance and frailty status and they should adopt disease-specific staging tools. Continuous positive airway pressure, mainly delivered through a helmet as elective method, should be considered as initial treatment for all patients with respiratory failure associated with COVID-19. In case of persisting dyspnea and/or desaturation despite 4-6 hours of noninvasive ventilation, endotracheal intubation and invasive mechanical ventilation should be considered. In the early phase, muscle relaxant use and volume-controlled ventilation is recommended. Prone position should be performed in patients with PaO2/FiO2≤100 mmHg. For patients admitted to ICU with COVID-19 interstitial pneumonia, we do not recommend empiric antibiotic therapy for community-acquired pneumonia. Consultation of an infectious disease specialist is suggested before start of any antiviral therapy. In conclusion, the COVID-19 Lombardy ICU Network identified a list of best practice statements supported by the available evidence and clinical experience or identified as panel members expert opinions for the management of critically ill patients with COVID-19.

KEY WORDS: COVID-19; Respiratory distress syndrome, adult; Pandemics

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